Impact Statement- Dental Hygiene - AAPD



Impact Statement- Dental Hygiene

A plain language description of the request:

The Connecticut Society of Pediatric Dentists requests that the state of Connecticut maintain the current dental hygiene scope of practice. The proposed scope of practice change for the Advanced Dental Hygiene Practitioner (ADHP) as submitted by the Connecticut Dental Hygiene Association is impractical and contrary to the goal of creating access to the full range of dental services to vulnerable populations within the state of Connecticut. The current scope of practice better maintains the integrity of dental services by requiring the supervision of a licensed dentist for licensed dental hygienists. Potential harm to the populace should the ADHP model be implemented includes:

• Reduced access to the full range of dental services available in a dental office

• A two tier system of care, whereby the most vulnerable among the population (and also those most at risk for dental disease) receive limited dental services provided by a less-well trained provider and those who are able to afford a higher quality of care receiving the full range of services provided by a licensed dentist

• The possibility of medical harm when services are provided by an ADHP who may encounter medical complications for which they are neither trained nor prepared to deal with

The Connecticut Society of Pediatric Dentists believes that all Americans deserve access to quality oral health care that is provided by fully educated and trained dentists and the teams that support them.

Public health and safety benefits that the requestor believes will be achieved should the request be implemented and, if applicable, a description of any harm to public health and safety should the request not be implemented:

Research indicates that the oral health care of children is best managed within the context of a dental office, or “dental home”. According to the AAPD Policy statement on Dental Home, “The dental home is inclusive of all aspects of oral health that result from the interaction of the patient, parents, non-dental professionals, and dental professionals. Establishment of the dental home is initiated by the identification and interaction of these individuals, resulting in a heightened awareness of all issues impacting the patient’s oral health.”[i] A Dental Home:

• Is an ongoing relationship between the patient and the dentist or dental team that is coordinated/supervised by a dentist

• Provides comprehensive, coordinated, oral health care that is continuously accessible and family-centered.

• Is an approach to assuring that all children have access to preventative and restorative oral health care.

The need for dental services to be conducted within the context of a dental home is highlighted by Casamassimo and Nowak (2002), “Children who have a dental home are more likely to receive appropriate preventive and routine oral health care. Referral by the primary care physician or health provider has been recommended, based on risk assessment, as early as 6 months of age, 6 months after the first tooth erupts, and no later than 12 months of age. Furthermore, subsequent periodicity of reappointment is based upon risk assessment. This provides time-critical opportunities to implement preventive health practices and reduce the child’s risk of preventable dental/oral disease.”[ii] Removing the dental hygienists from the dental home, as requested by the CT Dental Hygiene Association, will compromise the availability of the full range of services required for optimal oral care.

Additionally, the ADHP, as envisioned by the American Dental Hygiene Association and the CT Dental Hygiene Association does not call for adequate education or training to prepare a hygienist to safely practice dentistry of the highest quality. It is a model which would allow a dental hygienist with a Master’s degree education to practice dentistry without the benefit of the full range of educational experiences required for dentist licensure. Allowing the dental hygienist to practice without the supervision of a dentist (the model calls for a “collaborative management agreement) increases the possibility of the dental hygienist conducting procedures beyond his/her skill and education level, elevating the risk medical harm.

The impact that the request will have on public access to health care:

Should the Advanced Dental Hygiene Practitioner scope of practice request that was submitted by the Connecticut Dental Hygiene Association be enacted, public access to oral care would be diminished. Research indicates that, when the independent practice of dental hygiene is allowed, vulnerable populations, such as those enrolled in public insurance programs have decreased access to the full range of dental services provided in a dental home. This point is explicitly outlined in a 2007 Technical Issue Brief issued by the MCHB National Oral Health Policy Center which states, “Although such approaches have the potential to facilitate children’s access to Medicaid dental services, they do not -- in and of themselves -- meet the definition of dental services or the comprehensive services requirements stipulated in EPSDT service statutes.”[iii]

When hygiene services are performed outside the context of a dental home and without the supervision of a dentist, according to Schneider, et al (2007), “Such models may, in fact, be counterproductive if they alienate dentists currently participating in Medicaid or become barriers to recruitment of additional dentists. Common sources of frustration with respect to alternative models for dentists who participate in Medicaid generally stem from interruption in patient-provider relationships and duplication of services, which sometimes results in denial of payment for services.”[iv]

Currently, Connecticut citizens enjoy a high degree of access to dental services. According to a Press Release released by the CT Department of Public Health, children in Connecticut were less likely to have decay than other states, as evidenced by an open-mouth basic screening survey of Head Start, kindergarten and third grade children in the state during the 2006-2007 school year [v] For older adults in Connecticut, “dental care for older adults is available in private dental practices, in primary care settings such as community health centers, community adult dental centers and hospital clinics. To a limited extent, dental facilities are also available within nursing homes. However, many older adults are not aware of where or how to access dental services in their community.”[vi] Even so, adults in CT access dental care at a higher rate that all other states. According to the CDC, in 2008, 78.6% of adults age 18+ have visited a dental office or dental clinic in the past year, compared to 68.5% nationally. CT had the highest percentage of adults reporting a dental visit in the past year in the country.[vii]

Additionally, many of CT’s dentists participate in the Medicaid system. According to the Synopsis of State and Territorial Dental Public Health Programs by state, CT has no counties in the state that do not have a Medicaid-enrolled dentist. In fact, every county in CT has a dentist who saw at least 50 beneficiaries under the age of 21.[viii]

|Total of county population without a |0 |

|dentist.   | |

|  |Total population of counties in state without an enrolled Medicaid dentist   |0 |

|  |Number of counties in state without an enrolled Medicaid dentist   |0 |

|  |Number of counties in state without Medicaid billing dentist who saw 50+ beneficiaries under|0 |

| |age 21   | |

Currently, in CT[ix]:

• More than 1,000 dental providers actively participating in the Partnership – a gain of more than 800 providers.

• Nearly 73,000 children are now receiving dental care through the Dental Health Partnership, a 60% increase since the program’s inception.

• Since September 2008, dentists provided nearly $23.75 million in care to children in the Partnership program.

The access currently enjoyed by Medicaid recipients in Connecticut – amongst the best in the nation – could be compromised by the implementation of the ADHP model. Therefore, it is critical, for the benefit of the public that the model not be implemented. An alternative model, identified in a separate impact statement submitted by the Connecticut Society of Pediatric Dentists, the change in dental assisting scope of practice to include the Expanded Function Dental Auxiliaries, allows for provide for the education, training, and certification of an Expanded Functions Dental Auxiliary (EFDA). An EFDA is a highly trained and skilled dental assistant or dental hygienist who receives additional education to enable them to perform reversible, intraoral procedures, and additional tasks (expanded duties or extended duties), services or capacities, often including direct patient care services, which may be legally delegated by a licensed dentist under the supervision of a licensed dentist. The EFDA practices under the supervision of a licensed dentist. Connection to the dental home ensures that individuals will have access to comprehensive care, including restorative services to eliminate pain and restore function. This model also allows for provision of preventive oral health education by EFDAs and preventive oral health services by a dental hygienist under general supervision (ie, without the presence of the supervising dentist in the treatment facility) following the examination, diagnosis, and treatment plan by the licensed, supervising dentist.

A brief summary of state or federal laws that govern the health care profession making the request:

The registered Dental Hygienist (RDH) is an oral health professional licensed in each state. Licensing requirements and scope of practice for the licensed registered dental hygienist in CT is outlined in Chapter 379a of the CT General Statutes, CGS, which stipulates that in order to qualify for dental hygiene licensure in CT, which states:

Each application for a license to practice dental hygiene shall be in writing and signed by the applicant and accompanied by satisfactory proof that such person has received a diploma or certificate of graduation from a dental hygiene program with a minimum of two academic years of curriculum provided in a college or institution of higher education the program of which is accredited by the Commission on Dental Accreditation or such other national professional accrediting body as may be recognized by the United States Department of Education, and a fee of one hundred fifty dollars.

The "practice of dental hygiene" means the performance of educational, preventive and therapeutic services including: Complete prophylaxis; the removal of calcerous deposits, accretions and stains from the supragingival and subgingival surfaces of the teeth by scaling, root planing and polishing; the application of pit and fissure sealants and topical solutions to exposed portions of the teeth; dental hygiene examinations and the charting of oral conditions; dental hygiene assessment, treatment planning and evaluation; the administration of local anesthesia in accordance with the provisions of subsection (d) of this section; and collaboration in the implementation of the oral health care regimen.

(b) No person shall engage in the practice of dental hygiene unless such person (1) has a dental hygiene license issued by the Department of Public Health and (A) is practicing under the general supervision of a licensed dentist, or (B) has been practicing as licensed dental hygienist for at least two years, is practicing in a public health facility and complies with the requirements of subsection (e) of this section, or (2) has a dental license.[x]

The state’s current regulatory oversight of the health care profession making the request:

The dentist is a licensed professional and practices under the regulations set forth in the Connecticut State Statutes pertaining to Dentistry; Chapter 379a.

The department regulates access to the health care professions as well as community-based and environmental providers, and provides regulatory oversight of health care facilities, drinking water systems, and other services. 

All current education, training and examination requirements and any relevant certification requirements applicable to the health care profession making the request:

Currently, CT General Statutes Chapter 397 Sec. 20-126i states: Application for license. (a) Each application for a license to practice dental hygiene shall be in writing and signed by the applicant and accompanied by satisfactory proof that such person has received a diploma or certificate of graduation from a dental hygiene program with a minimum of two academic years of curriculum provided in a college or institution of higher education the program of which is accredited by the Commission on Dental Accreditation or such other national professional accrediting body as may be recognized by the United States Department of Education, and a fee of one hundred fifty dollars.[xi]

The ADHP, as envisioned by the American Dental Hygiene Association and the CT Dental Hygiene Association does not call for adequate education or training to prepare a hygienist to safely practice dentistry of the highest quality. It is a model which would allow a dental hygienist with a Master’s degree education to practice dentistry without the benefit of a dental school degree, and without the supervision of a dentist (the model calls for a “collaborative management agreement). All of these duties will be permitted to be done on the most medically and/or behaviorally complicated members of our society with NO direct supervision. A Master’s level education is simply not adequate to ensure the highest quality of dental care and patient safety.

In contrast, in addition to a college education, dental students spend 4 years learning the biological principles, diagnostic skills, and clinical techniques to distinguish between health and disease and to manage oral conditions while taking into consideration a patient’s general health and well-being. The clinical care they provide during their doctoral education is under direct supervision. Those who specialize in pediatric dentistry must spend an additional 24 or more months in a full time post-doctoral program that provides advanced didactic and clinical experiences.[xii] The skills that pediatric dentists develop are applied to the needs of children through their ever-changing stages of dental, physical, and psychosocial development, treating conditions and diseases unique to growing individuals.

A summary of known scope of practice changes either requested or enacted concerning the health care profession in the five-year period preceding the date of this request:

The extent to which the request directly impacts existing relationships within the health care delivery system:

Implementing the Scope of Practice change as requested by the CDHA would negatively impact the working relationship of the dental TEAM. Independent hygienists would be competing for patients without being able to provide the full range of dental services that are typically delivered in the dental office. Individuals who utilize these ADHPs may find themselves with compromised access to the dentist due to the lack of coordination of services inherent when dental hygienists are allowed to practice and bill for services without the benefit of a supervising dentist. As described above, this provision of services may result in frustrations due to an interruption in the patient-dentist relationship and in frustration over declined reimbursement due to duplicate billing.

The anticipated economic impact of the request on the health care delivery system:

It is anticipated that the ADHP model, as proposed by the CDHA would have a negative economic impact on the health care delivery system. CT currently enjoys a high degree of access to dental services provided by dentists as evidenced by the following:

• There are no counties within the state that do not have a Medicaid-participating dentist. Additionally, all counties in the state have a dentist who is actively serving more than 50 Medicaid recipients.

• According to the CDC, CT had the highest percentage of adults reporting a dental visit in the past year in the country.

• According to the Connecticut Department of Social Services in their written testimony HB 5616 in 2011, “the Department feels very strongly that access is no longer as great a concern as they once were. Our Dental Health Partnership (formally known as Husky) has made great strides over the last few years in increasing participation and pairing recipients with providers.”

• CT was one of 7 states to receive a grade of A by the PEW Center for the states in its annual “State of Children’s Dental Health” report. CT received this award in both 2010 and 2011.[xiii]

The financial investment in the ADHP would be substantial. Based on financial information from Fones School of Dental Hygiene in Bridgeport the student would have to spend approximately $135,000-$150,000 in order to obtain the Master’s-level education outlined by the CDHA request. These new providers, should they be enabled to practice independently, would have overhead and operating costs on par with dentists, limiting their ability to provide services to individuals that could not otherwise afford dental care. There is no evidence to support the financial efficacy of an independent hygiene practice.

The substantial financial investment of implementing the ADHP program combined with the limited opportunity for increasing access to dental services in CT would lead to the conclusion that implementing the scope of practice change would have negative economic implications.

Regional and national trends concerning licensure of the health care profession making the request and a summary of relevant scope of practice provisions enacted in other states:

Each state enacts its own laws determining the licensing and scope of practice guidelines for the practice of dental hygiene. While some states have enacted legislation allowing for some level of independent hygiene practice, no state to date has allowed for the ADHP model as proposed by the CT Dental Hygienists Association. The majority of states that allow services to be performed outside the dentist office by dental hygienists limit these services to preventive oral health care, such as hygiene instruction and the administration of fluoride varnish and dental sealants – 35 states fall into this category.

In all existing and proposed non-dentist provider models, the clinician receives abbreviated levels of education compared to the educational requirements of a dentist. For example, the dental health aid therapist model in Alaska is a 2 year certificate program with a pre-requisite high school education, the educational requirement for licensure as a dental therapist in Minnesota is a baccalaureate or master's degree from a dental therapy program, and proposed legislation for dental therapists in Vermont requires a 2 year curriculum including at least 100hours of dental therapy clinical practice under the general supervision of a licensed dentist.

[xiv] There is no evidence to suggest that they deliver any expertise comparable to a dentist in the fields of diagnosis, pathology, trauma care, pharmacology, behavioral guidance, treatment plan development, and care of special needs patients. I

According to Casamassimo (2011):

True, there are examples of dental therapists worldwide, but no real evidence of its applicability in a country with a third of a billion people, a highly developed, overwhelmingly dominant private practice-based dental care system, an extremely high standard of care, expectations of the populace across all socioeconomic strata for a singular high quality of care, a dental education system hard-pressed to either finance and repopulate itself, and a dental public health infrastructure in significant decline with little hope of salvation on the horizon.[xv]

In fact, The Institute of Medicine (IOM) released two reports on oral health this summer. Neither endorsed the mid-level provider.

Identification of any health care professions that can reasonably be anticipated to be directly impacted by the request, the nature of the impact and efforts made by the requestor to discuss the request with such health care professions:

A description of how the request relates to the health care profession’s ability to practice to the full extent of the profession’s education and training:

The current scope of practice for the practice of dental hygiene as outlined in CT General Statutes, Chapter 397 allows Dental Hygienists to practice to the full extent of the professions education and training. Expanding that scope of practice would extend the practice of dental hygiene beyond the level of education and training necessary to attain that licensure.

The ADHP is a model which would allow a dental hygienist with a Master’s degree to practice The ADHP would among other competencies be allowed to perform irreversible surgical procedures without the supervision of a dentist (the model calls for a “collaborative management agreement). According to the CDHA proposal, the ADHP would serve the most medically and/or behaviorally complicated members of our society with NO direct supervision. A Master’s level education is simply not adequate to ensure the highest quality of dental care and patient safety.

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[i] American Academy of Pediatric Dentistry. Policy on the dental home. Reference Manual 2007-2008; 29(7): 22-23.

[ii] Nowak, AJ & Casamassimo, PS. The dental home: A primary care oral health concept. Journal of the American Dental Assoc, 2002; 133(1): 93-98.

[iii] Schneider DA, Rossetti, J, & Crall JJ. Assuring Comprehensive Dental Services in Medicaid and Head Start Programs: Planning and Implementation Considerations: a Technical Issue Brief. MCHB National Oral Health Policy Center. October, 2007.

[iv] Ibid.

[v] Connecticut Department of Public Health. Connecticut Tops in the Country for Oral Health Status of Children. 11/9/2007. Accessible at:

[vi] The Task Force On Oral Health Of Older Adults. Just the f.a.c.t.s. strategies to improve oral health of

older adults in Connecticut. A Task Force Report. Connecticut Department of Public Health. January, 2008.

[vii] National Oral Health Surveillance System. Oral Health Resources. Adults aged 18+ who have visited a dentist or dental clinic in the past year. Accessed 9-28-2011.

[viii] CDC National Center for Chronic Disease Prevention and Health Prevention Oral Health Resources. Synopses of State and Territorial Dental Public Health Programs Synopses by State: CT, 2009.

. Accessed 9-28-2011.

[ix]Davis, J. Dental Workforce in CT SustiNet Workforce Task Force Webinar. Connecticut State Dental Association. February 8, 2010. Available . Accessed 9-28-2011.

[x] CT General Statutes. Chapter 397. Dentistry.

[xi]Ibid.

[xii] American Dental Association Commission on Dental Accreditation. Accreditation Standards for Advanced Specialty Education Programs in Pediatric Dentistry. 1998;23. Available at: ”. Accessed March 13, 2011.

[xiii] The Pew Center on the States. The state of children’s dental health: Making coverage matter. 2011.

[xiv] American Academy of Pediatric Dentistry. Policy on workforce issues and delivery of oral health care services in a dental home. Adopted 2011. . Accessed 9-27-2011.

[xv] Casamassimo, P. Dental therapy: another tongue in the Babel of dental access for children. ODA Today. 04/01/2011.

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